PRACTICE DIARY

Chapter 61

Headache

Gina was one of my more hypochondriacal patients and one of the hardest to reassure. On this particular day, she wasn't feeling well enough to sit in my waiting room; she preferred to wait in her car. When her appointment time came, I sent her husband to get her. She was dressed in pajamas and a robe.

“Dr. Brown,” she said, “I've been miserable all weekend with lots of gas and diarrhea. I'm feeling gaseous all over, even in my chest. Do you think there's something wrong with my heart?”

It wasn't a conclusion I would have leapt to, especially after she denied chest pain or pressure, diaphoresis and shortness of breath, but she did have hypertension and took a statin. She also had a history of severe reflux disease and took a proton pump inhibitor daily. On examination, her belly was diffusely tender but non-surgical, and she was afebrile with stable vital signs. “Gina,” I said, “I think you have a bad case of gastroenteritis, and I'm going to prescribe something for your diarrhea and gas.” I was going to leave it at that, but I could feel she needed a bit more reassuring, so I said, “I'm also going to do some blood tests – a complete blood count and chemistry panel – to make sure you're OK. My reference lab should have the results back by tomorrow morning.” She seemed placated.

I finished seeing patients early that afternoon and was in the video store when the thought struck me: Maybe Gina wasn't a hypochondriac. Maybe her chest complaints were an atypical presentation of angina. I hadn't done an electrocardiogram and was feeling vulnerable. My head was starting to hurt as I considered what to do. The laboratory courier would be arriving at my office in 15 minutes. If I could get there before the courier, I could remove Gina's specimen from the batch, add a serum troponin to the list of tests and personally make the drop at the local hospital's lab, which could give me the results sooner. It worked. Several hours later, the lab notified me that everything was normal, but the troponin would take another hour or two.

I called Gina to see how she was doing. “My stomach is better,” she said, “but I'm really worried about my heart. I called the heart institute, and a nurse there told me that women can present differently than men when they have heart attacks. She said I should go to the emergency room and get an EKG.”

Now I was really glad I had done the tests locally and added the serum troponin. I told Gina about her negative tests and asked her to wait an hour longer before going to the hospital. When I hung up, I envisioned a night of admitting her to the intensive care unit as a rule out (or worse), and I took three aspirin. Finally, Sue called from the lab. “Dr. Brown, the serum troponin is less than 0.03.”

“Great news,” I said and immediately phoned Gina with the results.

As my headache subsided, I wondered: Did I go to too much trouble for an overly worried patient? Perhaps. All I know is that we both slept better that night.

Ticketed!

Adam, my hospitalist friend, was in a snit. The night before, while speeding to the hospital to take care of a critically ill patient, he was trailed by a police officer who turned on his lights and followed him into the parking lot. “Feel free to follow me into the ICU,” Adam yelled behind him as he ran into the building. Two hours later, Adam emerged to find a summons on his windshield.

Indignant and incredulous, Adam went home and dashed off a letter to the chief of police, detailing a California vehicle code that allows physicians to exceed speed limits when driving to emergencies. Without violating patient confidentiality, he described the case and ended with a plea for better relationships between the police and emergency medical staff members. He also hinted that he would appreciate anything that could be done to address the citation.

I couldn't resist teasing Adam that, with his sporty, turbo-charged Subaru WRX, he might have drawn some attention to himself. “Next time take the Jeep,” I advised.

I remember, in the “good old days,” getting pulled over by the California Highway Patrol for cruising home from the hospital at 70 miles per hour in my Toyota. (I couldn't very well say I was going to an emergency.) When the officer saw me, he said, “Hey, doc, you were going too fast. Slow down next time.” That was it. I knew all the officers from working nights in the ER, so there was camaraderie among us. Getting out of that speeding violation somehow made me feel like a real doctor.

Adam e-mailed the next day. “Guess what?” he said. “The chief tore up the ticket.”

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family medicine has to offer. No real patient names have been used.

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